N.J. Admin. Code § 10:55-2.3
Current through Register Vol. 57, No. 1, January 6, 2025
| HCPCS | Description | Maximum |
|---|---|---|
| Code | Fee | |
| Allowance $ | ||
| (a) ORTHOTIC DEVICES (L0100-L0999) | ||
| 1. SPINAL: CERVICAL | ||
| L0112 | Cranial cervical orthosis, congenital torticollis | 879.82 |
| type, with or without soft interface material, | ||
| adjustable range of motion joint, custom fabricated | ||
| L0113 | Cranial cervical orthosis, tortcollis type, with or | B.R. |
| without joint, with or without soft interface | ||
| material, prefabricated, includes fitting and | ||
| adjustment | ||
| L0120 | Cervical, flexible, nonadjustable (foam collar) | 13.04 |
| L0130 | Cervical, flexible, thermoplastic collar, molded to | 54.40 |
| patient | ||
| L0140 | Cervical, semi-rigid, adjustable (plastic collar) | 24.40 |
| L0150 | Cervical, semi-rigid, adjustable molded chin up | 75.20 |
| (plastic collar with mandibular/occipital piece) | ||
| L0160 | Cervical, semi-rigid, wire frame | 100.00 |
| occipital/mandibular support | ||
| L0170 | Cervical collar, molded to patient model | 300.00 |
| L0172 | Cervical collar, semi-rigid, thermoplastic foam, | 68.34 |
| two piece | ||
| L0174 | Cervical collar, semi-rigid, thermoplastic foam, | 113.90 |
| two piece with thoracic extension | ||
| 2. MULTIPLE POST COLLAR | ||
| L0180 | Cervical, multiple post collar occipital/mandibular | 163.80 |
| supports, adjustable | ||
| L0190 | Cervical, multiple post collar, | 240.00 |
| occipital/mandibular supports, adjustable cervical | ||
| bars (Somi, Guilford, Taylor types) | ||
| L0200 | Cervical, multiple post collar, | 175.00 |
| occipital/mandibular supports, adjustable cervical | ||
| bars, and thoracic extension | ||
| 3. SPINAL: THORACIC | ||
| L0210 | Thoracic rib belt, custom fitted | 13.20 |
| L0220 | Thoracic rib belt, custom fabricated | 24.40 |
| 4. SPINAL: THORACIC-LUMBAR-SACRAL ORTHOSIS (TLSO) | ||
| L0430 | Spinal orthosis, anterior-posterior-lateral | 880.92 |
| control, with interface material, custom fitted | ||
| (Dewall posture protector only) | ||
| L0450 | TLSO, flexible, provides trunk support, upper | 122.58 |
| thoracic region, produces intracavitary pressure to | ||
| reduce load on the intervertebral disks with rigid | ||
| stays or panel(s), includes shoulder straps and | ||
| closures, prefabricated, includes fitting and | ||
| adjustment | ||
| L0452 | TLSO, flexible, provides trunk support, upper | 264.68 |
| thoracic region, produces intracavitary pressure to | ||
| reduce load on the intervertebral disks with rigid | ||
| stays or panel(s), includes shoulder straps and | ||
| closures, custom fabricated | ||
| L0454 | TLSO, flexible, provides trunk support, extends | 220.09 |
| from sacrococcygeal junction to above T-9 vertebra, | ||
| restricts gross trunk motion in the sagittal plane, | ||
| produces intracavitary pressure to reduce load on the | ||
| intervertebral disks with rigid stays or panel(s), | ||
| includes shoulder straps and closures, prefabricated, | ||
| includes fitting and adjustment | ||
| L0456 | TLSO, flexible, provides trunk support, thoracic | |
| region, rigid posterior panel and soft anterior apron, | ||
| extends from the sacrococcygeal junction and | 220.96 | |
| terminates just inferior to the scapular spine, | ||
| restricts gross trunk motion in the sagittal plane, | ||
| produces intracavitary pressure to reduce load on the | ||
| intervertebral disks, includes straps and closures, | ||
| prefabricated, includes fitting and adjustment | ||
| L0458 | TLSO, triplanar control, modular segmented spinal | 440.57 |
| system, two rigid plastic shells, posterior extends | ||
| from the sacrococcygeal junction and terminates just | ||
| inferior to the scapular spine, anterior extends from | ||
| the symphysis pubis to the xiphoid, soft liner, | ||
| restricts gross trunk motion in the sagittal, coronal, | ||
| and transverse planes, lateral strength is provided by | ||
| overlapping plastic and stabilizing closures, includes | ||
| straps and closures, prefabricated, includes fitting | ||
| and adjustment | ||
| L0460 | TLSO, triplanar control, modular segmented spinal | 440.57 |
| system, two rigid plastic shells, posterior extends | ||
| from the sacrococcygeal junction and terminates just | ||
| inferior to the scapular spine, anterior extends from | ||
| the symphysis pubis to the sternal notch, soft liner, | ||
| restricts gross trunk motion in the sagittal, coronal, | ||
| and transverse planes, lateral strength is provided by | ||
| overlapping plastic and stabilizing closures, includes | ||
| straps and closures, prefabricated, includes fitting | ||
| and adjustment | ||
| L0462 | TLSO, triplanar control, modular segmented spinal | 440.57 |
| system, three rigid plastic shells, posterior extends | ||
| from the sacrococcygeal junction and terminates just | ||
| inferior to the scapular spine, anterior extends from | ||
| the symphysis pubis to the sternal notch, soft liner, | ||
| restricts gross trunk motion in the sagittal, coronal, | ||
| and transverse planes, lateral strength is provided by | ||
| overlapping plastic and stabilizing closures, includes | ||
| straps and closures, prefabricated, includes fitting | ||
| and adjustment | ||
| L0464 | TLSO, triplanar control, modular segmented spinal | 437.70 |
| system, four rigid plastic shells, posterior extends | ||
| from sacrococcygeal junction and terminates just | ||
| inferior to scapular spine, anterior extends from | ||
| symphysis pubis to the sternal notch, soft liner, | ||
| restricts gross trunk motion in sagittal, coronal, and | ||
| transverse planes, lateral strength is provided by | ||
| overlapping plastic and stabilizing closures, includes | ||
| straps and closures, prefabricated, includes fitting | ||
| and adjustment | ||
| L0466 | TLSO, sagittal control, rigid posterior frame and | 224.99 |
| flexible soft anterior apron with straps, closures and | ||
| padding, restricts gross trunk motion in sagittal | ||
| plane, produces intracavity pressure to reduce load on | ||
| intervertebral disks, includes fitting and shaping the | ||
| frame, prefabricated, includes fitting and adjustment | ||
| L0468 | TLSO, sagittal-coronal control, rigid posterior | |
| frame and flexible soft anterior apron with straps, | ||
| closures and padding, extends from sacrococcygeal | 276.04 | |
| junction over scapulae, lateral strength provided by | ||
| pelvic, thoracic, and lateral frame pieces, restricts | ||
| gross trunk motion in sagittal, and coronal planes, | ||
| produces intracavitary pressure to reduce load on | ||
| intervertebral disks, includes fitting and shaping the | ||
| frame, prefabricated, includes fitting and adjustment | ||
| L0470 | TLSO, triplanar control, rigid posterior frame and | 447.64 |
| flexible soft anterior apron with straps, closures and | ||
| padding, extends from sacrococcygeal junction to | ||
| scapular, lateral strength provided by pelvic, | ||
| thoracic, and lateral frame pieces, rotational | ||
| strength provided by subclavicular extensions, | ||
| restricts gross trunk motion in sagittal, coronal, and | ||
| transverse planes, produces intracavitary pressure to | ||
| reduce load on the intervertebral disks, includes | ||
| fitting and shaping the frame, prefabricated, includes | ||
| fitting and adjustment | ||
| L0472 | TLSO, triplanar control, hyperextension, rigid | 291.60 |
| anterior and lateral frame extends from symphysis | ||
| pubis to sternal notch with two anterior components | ||
| (one public and one sternal), posterior and lateral | ||
| pads with straps and closures, limits spinal flexion, | ||
| restricts gross trunk motion in sagittal, coronal, and | ||
| transverse planes, includes fitting and shaping the | ||
| frame, prefabricated, includes fitting and adjustment. | ||
| L0474 | TLSO, triplanar control, rigid posterior frame with | 499.65 |
| flexible soft apron anterior with multiple straps, | ||
| closures and padding, extends from sacrococcygeal | ||
| junction to scapula, lateral strength provided by | ||
| pelvic, thoracic, and lateral frame pieces, rotational | ||
| strength provided by subclavicular extensions, | ||
| restricts gross trunk motion in the sagittal, coronal, | ||
| and transverse planes, produces intracavitary pressure | ||
| to reduce load on the intervertebral disks, includes | ||
| fitting and shaping the frame, prefabricated, includes | ||
| fitting and adjustment | ||
| L0480 | TLSO, triplanar control, one piece rigid plastic | 1,035.33 |
| shell without interface liner, with multiple straps | ||
| and closures, posterior extends from sacrococcygeal | ||
| junction and terminates just inferior to scapular | ||
| spine, anterior extends from symphysis pubis to | ||
| sternal notch, anterior or posterior opening, | ||
| restricts gross trunk motion in sagittal, coronal, and | ||
| transverse planes, includes a carved plaster or | ||
| cad-cam model, custom fabricated | ||
| L0482 | TLSO, triplanar control, one piece rigid plastic | |
| shell with interface liner, multiple straps and | ||
| closures, posterior extends from sacrococcygeal | 1,153.79 | |
| junction and terminates just inferior to scapular | ||
| spine, anterior extends from symphysis pubis to | ||
| sternal notch, anterior or posterior opening, | ||
| restricts gross trunk motion in sagittal, coronal, and | ||
| transverse planes, includes a carved plaster or | ||
| cad-cam model, custom fabricated | ||
| L0484 | TLSO, triplanar control, two piece rigid plastic | 1,146.26 |
| shell without interface liner, with multiple straps | ||
| and closures, posterior extends from sacrococcygeal | ||
| junction and terminates just inferior to scapular | ||
| spine, anterior extends from symphysis pubis to | ||
| sternal notch, lateral strength is enhanced by | ||
| overlapping plastic, restricts gross trunk motion in | ||
| the sagittal, coronal, and transverse planes, includes | ||
| a carved plaster or cad-cam model, custom fabricated | ||
| L0486 | TLSO, triplanar control, two piece rigid plastic | 1,218.72 |
| shell with interface liner, multiple straps and | ||
| closures, posterior extends from sacrococcygeal | ||
| junction and terminates just inferior to scapular | ||
| spine, anterior extends from symphysis pubis to | ||
| sternal notch, lateral strength is enhanced by | ||
| overlapping plastic, restricts gross trunk motion in | ||
| the sagittal, coronal, and transverse planes, includes | ||
| a carved plaster or cad-cam model, custom fabricated | ||
| L0488 | TLSO, triplanar control, one piece rigid plastic | 895.12 |
| shell with interface liner, multiple straps and | ||
| closures, posterior extends from sacrococcygeal | ||
| junction and terminates just inferior to scapular | ||
| spine, anterior extends from symphysis pubis to | ||
| sternal notch, anterior or posterior opening, | ||
| restricts gross trunk motion in sagittal, coronal, and | ||
| transverse planes, prefabricated, includes fitting and | ||
| adjustment | ||
| L0490 | TLSO, sagittal-coronal control, one piece rigid | 677.26 |
| plastic shell, with overlapping reinforced anterior, | ||
| with multiple straps and closures, posterior extends | ||
| from sacrococcygeal junction and terminates at or | ||
| before the T-9 vertebra, anterior extends from | ||
| symphysis pubis to xiphoid, anterior opening, | ||
| restricts gross trunk motion in sagittal and coronal | ||
| planes, prefabricated, includes fitting and adjustment | ||
| 5. SPINAL: LUMBAR--SACRAL--ORTHOSIS (LSO)--FLEXIBLE | ||
| L0491 | TLSO, sagittal-coronal control, modular segmented | 475.12 |
| spinal system, two rigid plastic shells, posterior | ||
| extends from the sacroccygeal junction and terminates | ||
| just inferior to the scapular spine, anterior extends | ||
| from the symphysis pubis to the Xiphoid, soft liner, | ||
| restricts gross trunk motion in the sagittal and | ||
| coronal planes, lateral strength is provided by | ||
| overlapping plastic and stabilizing closures, includes | ||
| straps and closures, prefabricated, includes fitting | ||
| and adjustment | ||
| L0492 | TLSO, sagittal-coronal control, modular segmented | |
| spinal system, three rigid plastic shells, posterior | ||
| extends from the sacroccygeal junction and terminates | 312.11 | |
| just inferior to the scapular spine, anterior extends | ||
| from the symphysis pubis to the xiphoid, soft liner, | ||
| restricts gross trunk motion in the sagittal and | ||
| coronal planes, lateral strength is provided by | ||
| overlapping plastic and stabilizing closures, | ||
| prefabricated, includes fitting and adjustment | ||
| 6. SPINAL: SACROILIAC/FLEXIBLE | ||
| L0600 | Sacroiliac, flexible (sacroiliac surgical support), | 40.72 |
| custom fitted | ||
| L0610 | Sacroiliac, flexible (sacroiliac surgical support), | 89.28 |
| custom fabricated | ||
| 7. SEMI-RIGID | ||
| L0620 | Sacroiliac, semi-rigid (Goldthwaite, Osgood types), | 192.00 |
| with apron front | ||
| 8. SPINAL: CERVICAL-THORACIC-LUMBAR-SACRAL-HALO PROCEDURE | ||
| ANTERIOR-POSTERIOR-LATERAL CONTROL | ||
| L0621 | Sacroiliac orthosis, flexible, provides | 57.33 |
| pelvic-sacral support, reduces motion about the | ||
| sacroiliac joint, includes straps, closures, may | ||
| include pendulous abdomen design, may be | ||
| prefabricated, includes fitting and adjustment | ||
| L0622 | Sacroiliac orthosis, flexible, provides | 153.10 |
| pelvic-sacral support, reduces motion about the | ||
| sacroiliac joint, includes straps, closures, may | ||
| include pendulous abdomen design, custom fabricated | ||
| L0623 | Sacroiliac orthosis, provides pelvic-sacral | B.R. |
| support, with rigid or semi-rigid panels over the | ||
| sacrum and abdomen, reduces motion about the | ||
| sacroiliac joint, includes straps, closures, may | ||
| include pendulous abdomen design, prefabricated, | ||
| includes fitting and adjustment | ||
| L0624 | Sacroiliac orthosis, provides pelvic-sacral | B.R. |
| support, with rigid or semi-rigid panels placed over | ||
| the sacrum and abdomen, reduces motion about the | ||
| sacroiliac joint, includes straps, closures, may | ||
| include pendulous abdomen design, custom fabricated | ||
| L0625 | Lumbar orthosis, flexible provides lumbar support, | 34.07 |
| posterior extends from L-1 to below L-5 vertebra, | ||
| produces intracavitary pressure to reduce load on the | ||
| intervertebral discs, includes straps, closures, may | ||
| include pendulous abdomen design, shoulder straps, | ||
| stays prefabricated, includes fitting and adjustments | ||
| L0626 | Lumbar orthosis, sagittal control, with rigid | 48.22 |
| posterior panel(s), posterior extends from L-1 below | ||
| L-5 vertebra, produces intracavitary pressure to | ||
| reduce load on the invertebral discs, includes straps, | ||
| closures, may include padding, stays, shoulder straps, | ||
| pendulous abdomen design, prefabricated, includes | ||
| fitting and adjustment | ||
| L0627 | Lumbar orthosis, sagittal control, with rigid | |
| anterior and posterior panels, posterior extends from | 254.29 | |
| L-1 to below L-5 vertebra, produces intracavitary | ||
| pressure to reduce load on the invertebral discs, | ||
| includes straps, closures, may include padding, | ||
| shoulder straps, pendulous abdomen design, | ||
| prefabricated, includes fitting and adjustment | ||
| L0628 | Lumbar-sacral, flexible provides lumbo-sacral | 51.90 |
| support, posterior extends from sacrococcygeal | ||
| junction to T-9 vertebra, produces intracavitary | ||
| pressure to reduce load on the invertebral discs, | ||
| includes straps, closures, may include stays, shoulder | ||
| straps, pendulous abdomen design, prefabricated, | ||
| includes fitting and adjustment | ||
| L0629 | Lumbar-sacral orthosis, flexible, provides | B.R. |
| lumbo-sacral support, posterior extends from | ||
| sacrococcygeal junction to T-9 vertebra, produces | ||
| intracavitary pressure to reduce load on the | ||
| intervertebral discs, includes straps, closures, may | ||
| include stays, shoulder straps, pendulous abdomen | ||
| design, prefabricated, includes fitting and adjustment | ||
| L0630 | Lumbar-sacral orthosis, sagittal control, with | 100.19 |
| rigid posterior panel(s), posterior extends from | ||
| sacrococcygeal junction to T-9 vertebra, produces | ||
| intracavitary pressure to reduce load on the | ||
| intervertebral discs, includes straps, closures, may | ||
| include padding, stays, shoulder straps, pendulous | ||
| abdomen design, prefabricated, includes fitting and | ||
| adjustment | ||
| L0631 | Lumbar-sacral orthosis sagittal control, with rigid | 635.08 |
| anterior and posterior panels, posterior extends from | ||
| sacroccygeal junction T-9 vertebra, produces | ||
| intracavitary pressure to reduce load on the | ||
| intervertebral discs, includes straps, closures, may | ||
| include padding, shoulder straps, pendulous abdomen | ||
| design, prefabricated includes fitting and adjustment | ||
| L0632 | Lumbar-sacral orthosis sagittal control, with rigid | B.R. |
| anterior and posterior panels, posterior extends from | ||
| sacroccygeal junction T-9 vertebra, produces | ||
| intracavitary pressure to reduce load on the | ||
| intervertebral discs, includes straps, closures, may | ||
| include padding, shoulder straps, pendulous abdomen | ||
| design, prefabricated includes fitting and adjustment | ||
| custom fabricated | ||
| L0633 | Lumbar-sacral orthosis, sagittal-coronal control, | 177.39 |
| with rigid posterior frame/panel(s), posterior extends | ||
| from sacrococcygeal junction to T-9 vertebra, lateral | ||
| strength provided by rigid lateral frame/panels, | ||
| produces intracavitary pressure to reduce load on | ||
| intervertebral discs, includes straps, closures, may | ||
| include padding, stays, shoulder straps, penduloud | ||
| abdomen design, prefabricated, includes fitting and | ||
| adjustment | ||
| L0634 | Lumbar-sacral orthosis, sagittal-coronal, with | |
| rigid posterior frame/panel(s), posterior extends from | B.R. | |
| sacroccygeal junction to T-9 vertebra, lateral | ||
| strength provided by rigid lateral frame/panel(s), | ||
| produces intracavitary pressure to reduce load on | ||
| intervertebral discs, includes straps, closures, may | ||
| include padding, stays, shoulder straps, pendulous | ||
| abdomen design, custom fabricated | ||
| L0635 | Lumbar-sacral orthosis, sagittal-coronal control, | 603.06 |
| lumbar flexion rigid posterior frame/panels, lateral | ||
| articulating design to flex the lumbar spine, | ||
| posterior extends from sacrococcygeal junction T-9 | ||
| vertebra, lateral strength provided by rigid lateral | ||
| frames/panel(s), produces intracavitary pressure to | ||
| reduce load on intervertebral discs, include padding, | ||
| anterior panel, pendulous abdomen design, | ||
| prefabricated, includes fitting and adjustment | ||
| L0636 | Lumbar-sacral orthosis, sagittal-coronal control, | 894.38 |
| lumbar flexion, rigid posterior frames/panels, lateral | ||
| articulating design to flex the lumbar spine, | ||
| posterior extends from sacrococcygeal junction to T-9 | ||
| vertebra, lateral strength provided by rigid lateral | ||
| frame/panels, produces intracavitary pressure to | ||
| reduce load on intervertebral discs, includes straps, | ||
| closures, may include padding, anterior panel, | ||
| pendulous abdomen design, custom fabricated | ||
| L0637 | Lumbar-sacral orthosis, sagittal-coronal, control, | 664.58 |
| lumbarflexion, rigid posterior frame/panels, posterior | ||
| extends from sacrococcygeal junction to T-9 vertebra, | ||
| lateral sacrococcygeal junction to T-9 vertebra, | ||
| lateral, shoulder straps, pendulous abdomen design, | ||
| prefabricated includes fitting and adjustment | ||
| L0638 | Lumbar-sacral orthosis, sagittal-coronal control, | 815.91 |
| with rigid anterior and posterior frames/panels, | ||
| posterior extends from sacrococcygeal junction to T-9 | ||
| vertebra, lateral strength provided by rigid lateral | ||
| frames/panels, produces intracavitary pressure to | ||
| reduce load on intervertebral discs, includes straps, | ||
| closures, may include padding shoulder straps, | ||
| pendulous abdomen design, prefabricated includes | ||
| fitting and adjustment | ||
| L0639 | Lumbar-sacral orthosis, sagittal-coronal control, | 664.58 |
| rigid shell(s)/panel(s), posterior extends from | ||
| sacrococcygeal junction to T-9 vertebra, anterior | ||
| extends from symphysis pubis to xyphoid, produces | ||
| intracavitary pressure to reduce load on the | ||
| intervertebral discs, overall strength is provided by | ||
| overlapping rigid material and stabilizing closures, | ||
| includes straps, closures, may include soft interface, | ||
| pendulous abdomen design, custom prefabricated | ||
| includes fitting and adjustment | ||
| L0640 | Lumbar-sacral orthosis, sagittal-coronal control, | |
| rigid shell(s)/panel(s), posterior extends from | ||
| sacrococcygeal junction to T-9 vertebra, anterior | 647.33 | |
| extends from symphysis pubis to xyphoid, produces | ||
| intracavitary pressure to reduce load on the | ||
| intervertebral discs, overall strength is provided by | ||
| overlapping rigid material and stabilizing closures, | ||
| includes straps, closures, may include soft interface, | ||
| pendulous abdomen design, custom fabricated | ||
| L0700 | Cervical-thoracic-lumbarsacral-orthoses (CTLSO), | 1,160.00 |
| anterior-posterior-lateral-control, molded to patient | ||
| model (Minerva type) | ||
| L0710 | CTLSO, anterior-posterior-lateral-control, molded | 1,280.00 |
| to patient model, with interface material (Minerva | ||
| type) | ||
| 9. HALO PROCEDURE | ||
| L0810 | Halo procedure, cervical halo incorporated into | 1,677.11 |
| jacket vest | ||
| L0820 | Halo procedure, cervical halo incorporated into | 1,200.00 |
| plaster body jacket | ||
| L0830 | Halo procedure, cervical halo incorporated into | 2,053.61 |
| Milwaukee type orthosis | ||
| L0859 | Addition to halo procedure, magnetic resonance | 721.98 |
| image compatible systems, rings and pins, any material | ||
| L0861 | Addition to halo procedure, replacement liner, | 135.48 |
| interface material | ||
| 10. ADDITIONS TO SPINAL ORTHOSES | ||
| L0970 | TLSO, corset front | 33.60 |
| L0972 | LSO, corset front | 69.20 |
| L0974 | TLSO, full corset | 88.20 |
| L0976 | LSO, full corset | 103.88 |
| L0978 | Axillary crutch extension | 35.00 |
| L0980 | Peroneal straps, pair | 11.33 |
| L0982 | Stocking supporter grips, set of four (4) | 9.60 |
| L0984 | Protective body sock, each | 34.12 |
| L0999 | Addition to spinal orthosis, not otherwise | B.R. |
| specified | ||
| (b) ORTHOTIC DEVICES--SCOLIOSIS PROCEDURES (L1000-L1499) | ||
| The orthotic care of scoliosis differs from other care in that the | ||
| treatment is more dynamic in nature and uses ongoing continual modification of | ||
| the orthosis to the patient's changing condition. This coding structure uses | ||
| the proper names or eponyms of the procedures because they have historic and | ||
| universal acceptance in the profession. It should be recognized that | ||
| variations to the basic procedures described by the founders/developers are | ||
| accepted in various medical and orthotic practices throughout the country. All | ||
| procedures include model of patient when indicated. | ||
| 1. SCOLIOSIS: CERVICAL--THORACIC--LUMBAR--SACRAL ORTHOSIS | ||
| (CTLSO) (MILWAUKEE) | ||
| L1000 | Cervical-thoracic-lumbar-sacral orthosis (CTLSO), | 1,134.00 |
| inclusive of furnishing initial orthoses including | ||
| model | ||
| L1001 | Cervical-thoracic-lumbar-sacral orthosis, | B.R. |
| immobilizer, infant size, prefabricated, includes | ||
| fitting and adjustment | ||
| L1005 | Tension based scoliosis orthosis and accessory | 1,990.05 |
| pads, includes fitting and adjustment | ||
| L1010 | Additions to (CTLSO) or scoliosis orthosis, axilla | 44.88 |
| sling | ||
| L1020 | Addition to CTLSO or scoliosis orthosis, kyphosis | 25.00 |
| pad | ||
| L1025 | Addition to CTLSO or scoliosis orthosis, kyphosis | 77.29 |
| pad, floating | ||
| L1030 | Addition to CTLSO or scoliosis orthosis, lumbar | 40.83 |
| bolster pad | ||
| L1040 | Addition to CTLSO or scoliosis orthosis, lumbar or | 39.00 |
| lumbar rib pad | ||
| L1050 | Addition to CTLSO or scoliosis orthosis, sternal | 39.00 |
| pad | ||
| L1060 | Addition to CTLSO or scoliosis orthosis, thoracic | 39.00 |
| pad | ||
| L1070 | Addition to CTLSO or scoliosis orthosis, trapezius | 51.00 |
| sling | ||
| L1080 | Addition to CTLSO or scoliosis orthosis, outrigger | 35.42 |
| L1085 | Addition to CTLSO or scoliosis orthosis, outrigger | 108.45 |
| bilateral with vertical extensions | ||
| L1090 | Addition to CTLSO or scoliosis orthosis, lumbar | 51.00 |
| sling | ||
| L1100 | Addition to CTLSO or scoliosis orthosis, ring | 66.00 |
| flange, plastic or leather | ||
| L1110 | Addition to CTLSO or scoliosis orthosis, ring | 90.00 |
| flange, plastic or leather, molded to patient model | ||
| L1120 | Addition to CTLSO or scoliosis orthosis, cover for | 26.05 |
| upright, each | ||
| 2. SCOLIOSIS: THORACIC--LUMBAR--SACRAL ORTHOSIS (TLSO) (LOW | ||
| PROFILE) | ||
| L1200 | Thoracic-lumbar-sacral-orthosis (TLSO), inclusive | 1,037.53 |
| of furnishing initial orthosis only | ||
| L1210 | Additions to TLSO, (low profile), lateral thoracic | 175.00 |
| extension | ||
| L1220 | Additions to TLSO, (low profile), anterior thoracic | 175.00 |
| extension | ||
| L1230 | Additions to TLSO, (low profile), Milwaukee type | 340.00 |
| superstructure | ||
| L1240 | Additions to TLSO, (low profile), lumbar derotation | 44.75 |
| pad | ||
| L1250 | Addition to TLSO, (low profile), anterior asis pad | 44.75 |
| L1260 | Addition to TLSO, (low profile), anterior thoracic | 44.75 |
| derotation pad | ||
| L1270 | Addition to TLSO, (low profile), abdominal pad | 44.75 |
| L1280 | Addition to TLSO, (low profile), rib gusset | 61.02 |
| (elastic), each | ||
| L1290 | Addition to TLSO, (low profile), lateral | 40.68 |
| trochanteric pad | ||
| 3. OTHER SCOLIOSIS PROCEDURES | ||
| L1300 | Other scoliosis procedure, body jacket molded to | 1,200.00 |
| patient model | ||
| L1310 | Other scoliosis procedure, post-operative body | 1,200.00 |
| jacket | ||
| L1499 | Unlisted procedure for spinal orthosis | B.R. |
| 4. THORACIC--HIP--KNEE--ANKLE ORTHOSIS (THKAO) | ||
| L1500 | Thoracic-hip-knee-ankle orthoses (THKAO), mobility | 1,243.33 |
| frame (Newington, Parapodium types) | ||
| L1510 | THKAO, standing frame | 877.67 |
| L1520 | THKAO, swivel walker | 1,487.44 |
| (c) ORTHOTIC DEVICES--LOWER LIMB (L1600-L2699) | ||
| The procedures in L1600-L2999 are considered as "base" or "basic | ||
| procedures" and may be modified by listing procedures from the "additions" | ||
| sections and adding them to the base procedures. | ||
| 1. LOWER LIMB: HIP--FLEXIBLE | ||
| L1600 | Hip orthoses (HO), abduction control of hip joints, | 40.32 |
| flexible, Frejka type with cover | ||
| L1610 | HO, abduction control of hip joints, flexible, | 25.00 |
| (Frejka cover only) | ||
| L1620 | HO, abduction control of hip joints, flexible, | 75.00 |
| (Pavlik harness) | ||
| L1630 | HO, abduction control of hip joints, semi-flexible | 111.31 |
| (Von Rosen type) | ||
| L1640 | HO, abduction control of hip joints, static, pelvic | 250.00 |
| band or spreader bar, thigh cuffs | ||
| L1650 | HO, abduction control of hip joints, static, | 150.00 |
| adjustable, custom fitted (Ilfled type) | ||
| L1652 | Hip orthosis, bilateral thigh cuffs with adjustable | 224.08 |
| abductor spreader bar, adult size, prefabricated, | ||
| includes fitting and adjustment, any type | ||
| L1660 | HO, abduction control of hip joints, static, | 109.07 |
| plastic, custom fitted | ||
| L1680 | HO, abduction control of hip joints, dynamic, | 802.72 |
| pelvic control, adjustable hip motion control, thigh | ||
| cuffs (Rancho hip action type) | ||
| L1685 | HO, abduction control of hip joints, postoperative | 610.20 |
| hip adduction type, custom fabricated | ||
| L1686 | HO, abduction control of hip joint, postoperative | 600.00 |
| hip abduction type, custom fitted | ||
| L1690 | Combination, bilateral, lumbo-sacral, hip, femur | 1,040.29 |
| orthosis providing adduction and internal rotation | ||
| control | ||
| 2. LOWER LIMB--LEGG PERTHES | ||
| L1700 | Legg Perthes orthosis, (Toronto type) | 996.07 |
| L1710 | Legg Perthes orthosis, (Newington type) | 1,159.26 |
| L1720 | Legg Perthes orthosis, trilateral, (Tachdijan type) | 852.85 |
| L1730 | Legg Perthes orthosis, (Scottish Rite type) | 739.21 |
| L1750 | Legg Perthes orthosis, Legg Perthes sling (Sam | 80.00 |
| Brown | ||
| L1755 | Legg Perthes orthosis, (Patten Bottom type) | 854.40 |
| 3. LOWER LIMB: KNEE | ||
| L1810 | KO, elastic with joints | 61.04 |
| L1820 | KO, elastic with condyle pads and joints | 72.40 |
| L1830 | KO, immobilizer; canvas longitudinal | 52.88 |
| L1831 | KO, Locking knee joint(s), positional orthosis, | 185.00 |
| prefabricated includes fitting and adjustment | ||
| L1832 | KO, adjustable knee joints, positional orthosis, | 320.00 |
| rigid support, custom fitted | ||
| L1834 | KO, without knee joint, rigid, molded to patient | 388.00 |
| model | ||
| L1836 | Knee orthosis, rigid, without joint(s), includes | 83.87 |
| soft interface material, prefabricated, includes | ||
| fitting and adjustment | ||
| L1840 | KO, derotation, medial-lateral, anterior cruciate | 520.00 |
| ligament, custom fabricated to patient model | ||
| L1843 | Knee orthosis (KO); single upright, thigh and calf, | 392.81 |
| with adjustable flexion and extension joint, | ||
| medial-lateral and rotation control, custom fitted | ||
| L1844 | KO, single upright, thigh and calf, with adjustable | 852.38 |
| flexion and extension joint, medial-lateral and | ||
| rotation control, molded to patient model | ||
| L1845 | KO, double upright, thigh and calf, with adjustable | 468.00 |
| flexion and extension joint, medial-lateral and | ||
| rotation control, custom fitted | ||
| L1846 | KO, double upright, thigh and calf, with adjustable | 528.80 |
| flexion and extension joint, medial-lateral and | ||
| rotation control, molded to patient model | ||
| L1847 | Knee orthosis (KO); double upright with adjustable | 309.42 |
| joint, with inflatable air support chamber(s) | ||
| L1850 | KO, Swedish type | 148.00 |
| L1858 | KO, molded plastic, polycentric knee joints, | 610.20 |
| pneumatic knee pads (CTI) | ||
| L1860 | KO, modification of supracondylar prosthetic | 555.68 |
| socket, molded to patient model (SK) | ||
| 4. LOWER LIMB: ANKLE-FOOT | ||
| L1900 | Ankle-foot orthoses (AFO), spring wire, | 158.64 |
| dorsiflexion assist calf band | ||
| L1901 | Ankle orthosis, elastic, prefabricated, includes | 11.13 |
| fitting and adjustment (for example, neoprene, lycra) | ||
| L1902 | AFO, ankle gauntlet, custom fitted | 48.81 |
| L1904 | AFO, molded ankle gauntlet, molded to patient model | 284.76 |
| L1906 | AFO, multiligamentus ankle support | 75.00 |
| L1907 | AFO, Supramalleolar with straps, with or without | 353.71 |
| interface/pads, custom fabricated | ||
| L1910 | AFO, posterior, single bar, clasp attachment to | 192.99 |
| shoe counter | ||
| L1920 | AFO, single upright with static or adjustable stop | 200.00 |
| (Phelps or Perlstein type) | ||
| L1930 | AFO, custom fitted, plastic | 156.80 |
| L1932 | AFO, rigid anterior tibial section, total carbon | 552.04 |
| fiber equal material, prefabricated, includes fitting | ||
| and adjustment | ||
| L1940 | AFO, molded to patient model, plastic | 387.94 |
| L1945 | AFO, molded to patient model, plastic, rigid | 540.00 |
| anterior tibial section (floor reaction) | ||
| L1950 | AFO, spiral, molded to patient model (Irm type), | 593.22 |
| plastic | ||
| L1951 | AFO, spiral, (Institute of Rehabilitative Medicine | 527.61 |
| type), plastic or other material, prefabricated, | ||
| includes fitting and adjustment | ||
| L1960 | AFO, posterior solid ankle, molded to patient | 421.60 |
| model, plastic | ||
| L1970 | AFO, plastic molded to patient model, with ankle | 513.35 |
| joint | ||
| L1971 | AFO, plastic or other material, with ankle joint, | 294.64 |
| prefabricated, includes fitting and adjustment | ||
| L1980 | AFO, single upright free plantar dorsiflexion, | 229.60 |
| solid stirrup, calf band/cuff (single bar "BK" | ||
| orthosis) | ||
| L1990 | AFO, double upright free plantar dorsiflexion, | 287.20 |
| solid stirrup, calf band/cuff (double bar "BK" | ||
| orthosis) | ||
| X4005 | Tone reducing orthoses knee high, custom molded, | 1,121.00 |
| supply by orthotist, each | ||
| X4006 | Tone reducing orthoses ankle high, custom molded, | 350.00 |
| supply by orthotist, each | ||
| X4007 | Swedo ankle orthoses, each | 90.00 |
| X4450 | AFO, posterior leaf spring molded to patient model | 386.40 |
| (Tirr, Rancho) includes casting | ||
| 5. LOWER LIMB: HIP-KNEE-ANKLE-FOOT ORTHOSIS (KAFO)--OR ANY | ||
| COMBINATION | ||
| L2000, L2020, and L2036 are base procedures which may be used with any | ||
| knee joint; L2010 and L2030 shall only be used with no knee joint. | ||
| L2000 | Knee-ankle-foot-orthoses (KAFO), single upright, | 760.00 |
| free knee, free ankle, solid stirrup, thigh and calf | ||
| bands/cuffs (single bar "AK" orthosis) | ||
| L2005 | Knee-ankle-foot-orthosis (KAFO); single or double | 2,534.97 |
| upright, stance control, automatic lock and swing | ||
| phase release, mechanical activation, includes ankle | ||
| joint, any type, custom fabricated | ||
| L2010 | KAFO, single upright, free ankle, solid stirrup, | 568.68 |
| thigh and calf bands/cuffs (single bar "AK" orthosis), | ||
| without knee joint | ||
| L2020 | KAFO, double upright, free knee, free ankle, solid | 786.13 |
| stirrup, thigh and calf bands/cuffs (double bar "AK" | ||
| orthosis) | ||
| L2030 | KAFO, double upright, free ankle, solid stirrup, | 571.20 |
| thigh and calf bands/cuffs (double bar "AK" orthosis), | ||
| without knee joint | ||
| L2034 | Full plastic single upright, with or without free | 1,289.57 |
| motion knee, medial lateral, rotation control, with or | ||
| without free motion ankle, custom fabricated | ||
| L2035 | Knee-ankle-foot-orthosis (KAFO); full plastic, | B.R. |
| static, prefabricated (pediatric size) | ||
| L2036 | KAFO, full plastic, double upright, free knee, | 1,000.00 |
| molded to patient model | ||
| L2037 | KAFO, full plastic, single upright, free knee, | 900.00 |
| molded to patient model | ||
| L2038 | KAFO, full plastic, without knee joint, multiaxis | 900.00 |
| molded to patient model (lively orthosis or equal) | ||
| 6. TORSION CONTROL | ||
| L2040 | Hip-knee-ankle-foot orthosis (HKAFO), torsion | 131.05 |
| control, bilateral rotation straps, pelvic band/belt | ||
| L2050 | HKAFO, torsion control, bilateral torsion cables, | 223.44 |
| hip joint, pelvic band/belt | ||
| L2060 | HKAFO, torsion control, bilateral torsion cables, | 250.00 |
| ball bearing hip joint, pelvic band/belt | ||
| L2070 | HKAFO, torsion control, unilateral rotation straps, | 90.76 |
| pelvic band/belt | ||
| L2080 | HKAFO, torsion control, unilateral torsion cable, | 200.00 |
| hip joint, pelvic band/belt | ||
| L2090 | HKAFO, torsion control, unilateral torsion cable, | 200.00 |
| ball bearing hip joint, pelvic band/belt | ||
| 7. FRACTURE ORTHOSES | ||
| L2106 | AFO, fracture orthosis, tibial fracture cast | 284.76 |
| orthosis, thermoplastic type casting material, molded | ||
| to patient | ||
| L2108 | AFO, fracture orthosis, tibial fracture cast | 569.60 |
| orthosis, molded to patient model | ||
| L2112 | AFO, fracture orthosis, tibial fracture orthosis, | 244.08 |
| soft custom fitted | ||
| L2114 | AFO, fracture orthosis, tibial fracture orthosis, | 321.37 |
| semi-rigid custom fitted | ||
| L2116 | AFO, fracture orthosis, tibial fracture orthosis, | 366.40 |
| rigid custom fitted | ||
| L2126 | KAFO, fracture orthosis, femoral fracture cast | 651.20 |
| orthosis, thermoplastic type casting material, molded | ||
| to patient | ||
| L2128 | KAFO, fracture orthosis, femoral fracture cast, | 895.20 |
| molded to patient model | ||
| L2132 | KAFO, fracture orthosis, femoral fracture cast | 488.16 |
| orthosis, soft custom fitted | ||
| L2134 | KAFO, fracture orthosis, femoral fracture cast | 528.81 |
| orthosis, semi-rigid custom fitted | ||
| L2136 | KAFO, fracture orthosis, femoral fracture cast | 630.40 |
| orthosis, rigid custom fitted | ||
| 8. ADDITIONS TO FRACTURE ORTHOSIS | ||
| L2180 | Addition to lower extremity fracture orthosis, | 53.69 |
| plastic shoe insert with ankle joints | ||
| L2182 | Addition to lower extremity fracture orthosis, drop | 48.80 |
| lock knee joint | ||
| L2184 | Addition to lower extremity fracture orthosis, | 69.16 |
| limited motion knee joint | ||
| L2186 | Addition to lower extremity fracture orthosis, | 101.70 |
| adjustable motion knee joint, Lerman type | ||
| L2188 | Addition to lower extremity fracture orthosis, | 203.40 |
| quadrilateral brim | ||
| L2190 | Addition to lower extremity fracture orthosis, | 48.81 |
| waist belt | ||
| L2192 | Addition to lower extremity fracture orthosis, hip | 203.40 |
| joint pelvic band, thigh flange, and pelvic belt | ||
| 9. ADDITIONS TO LOWER EXTREMITY ORTHOSIS; | ||
| SHOE--ANKLE--SHIN--KNEE | ||
| L2200 | Addition to lower extremity, limited ankle motion, | 30.80 |
| each joint | ||
| L2210 | Addition to lower extremity, dorsiflexion assist | 48.00 |
| (plantar flexion resist), each joint | ||
| L2220 | Addition to lower extremity, dorsiflexion and | 59.65 |
| plantar flexion assist/resist, each joint | ||
| L2230 | Addition to lower extremity, split flat caliper | 49.95 |
| stirrups and plate attachment | ||
| L2232 | Addition to lower extremity orthosis, rocker bottom | 61.57 |
| for total contact ankle foot orthosis, for custom | ||
| fabricated orthosis only | ||
| L2240 | Addition to lower extremity, round caliper and | 54.10 |
| plate attachment | ||
| L2250 | Addition to lower extremity, foot plate, molded to | 234.08 |
| patient model, stirrup attachment | ||
| L2260 | Addition to lower extremity, reinforced solid | 169.83 |
| stirrup (Scott-Craig type) | ||
| L2265 | Addition to lower extremity, long tongue stirrup | 32.00 |
| L2270 | Addition to lower extremity, varus/valgus | 35.03 |
| correction ("T") strap, padded/lined or malleolus pad | ||
| L2275 | Addition to lower extremity, varus/vulgus | 65.71 |
| corrections, plastic modification, padded/lined | ||
| L2280 | Addition to lower extremity, molded inner boot | 105.76 |
| L2300 | Addition to lower extremity, abduction bar | 175.00 |
| (bilateral hip involvement), jointed, adjustable | ||
| L2310 | Addition to lower extremity, abduction bar, | 80.01 |
| straight | ||
| L2320 | Addition to lower extremity, nonmolded lacer | 96.00 |
| L2330 | Addition to lower extremity, lacer molded to | 190.00 |
| patient model | ||
| L2335 | Addition to lower extremity, anterior swing band | 122.04 |
| L2340 | Addition to lower extremity, pretibial shell, | 284.80 |
| molded to patient model | ||
| L2350 | Addition to lower extremity, prosthetic type, (BK) | 447.52 |
| socket, molded to patient model (used for "PTB" "AFO" | ||
| orthoses) | ||
| L2360 | Addition to lower extremity, extended steel shank | 41.16 |
| L2370 | Addition to lower extremity, patten bottom | 164.00 |
| L2375 | Addition to lower extremity, torsion control, ankle | 75.80 |
| joint and half solid stirrup | ||
| L2380 | Addition to lower extremity, torsion control, | 32.00 |
| straight knee joint, each joint | ||
| L2385 | Addition to lower extremity, straight knee joint, | 52.88 |
| heavy duty, each joint | ||
| L2387 | Addition to lower extremity, polycentric knee | 98.08 |
| joint, for custom fabricated knee ankle foot orthosis, | ||
| each joint | ||
| L2390 | Addition to lower extremity, offset knee joint, | 52.88 |
| each joint | ||
| L2395 | Addition to lower extremity, offset knee joint, | 73.60 |
| heavy duty, each joint | ||
| L2397 | Addition to lower extremity orthosis, suspension | 61.53 |
| sleeve | ||
| 10. ADDITIONS TO STRAIGHT KNEE OR OFFSET KNEE JOINTS | ||
| L2405 | Addition to knee joint, drop lock, each joint | 24.80 |
| L2415 | Addition to knee joint, cam lock (Swiss, French | 101.60 |
| Bail types), each joint | ||
| L2425 | Addition to knee joint, disc or dial lock for | 142.00 |
| adjustable knee flexion, each joint | ||
| L2435 | Addition to knee joint, polycentric joint, each | 97.63 |
| joint | ||
| L2492 | Addition to knee joint, lift loop for drop lock | 68.80 |
| ring | ||
| 11. ADDITIONS--THIGH/WEIGHT BEARING--GLUTEAL/ISCHIAL WEIGHT | ||
| BEARING | ||
| L2500 | Addition to lower extremity, thigh/weight bearing, | 117.60 |
| gluteal/ischial weight bearing, ring | ||
| L2510 | Addition to lower extremity, thigh/weight bearing, | 508.81 |
| quadrilateral brim, molded to patient model | ||
| L2520 | Addition to lower extremity, thigh/weight bearing, | 336.00 |
| quadrilateral brim, custom fitted | ||
| L2525 | Addition to lower extremity, thigh/weight bearing, | 660.00 |
| ischial containment/narrow M-L brim molded to patient | ||
| model | ||
| L2526 | Addition to lower extremity, thigh/weight bearing, | 380.00 |
| ischial containment/narrow M-L brim, custom fitted | ||
| L2530 | Addition to lower extremity, thigh/weight bearing, | 146.48 |
| lacer, nonmolded | ||
| L2540 | Addition to lower extremity, thigh/weight bearing, | 196.00 |
| lacer, molded to patient model | ||
| L2550 | Addition to lower extremity, thigh/weight bearing, | 61.04 |
| high roll cuff | ||
| 12. ADDITIONS: PELVIC AND THORACIC CONTROL | ||
| L2570 | Addition to lower extremity, pelvic control, hip | 280.00 |
| joint, clevis type two position joint, each | ||
| L2580 | Addition to lower extremity, pelvic control, pelvic | 240.00 |
| sling | ||
| L2600 | Addition to lower extremity, pelvic control, hip | 108.00 |
| joint, clevis type, or thrust bearing, free, each | ||
| L2610 | Addition to lower extremity, pelvic control, hip | 132.00 |
| joint, clevis or thrust bearing, lock, each | ||
| L2620 | Addition to lower extremity, pelvic control, hip | 160.00 |
| joint, heavy-duty, each | ||
| L2622 | Addition to lower extremity, pelvic control, hip | 170.85 |
| joint, adjustable flexion, each | ||
| L2624 | Addition to lower extremity, pelvic control, hip | 102.40 |
| joint, adjustable flexion, extension, abduction | ||
| control, each | ||
| L2627 | Addition to lower extremity, pelvic control, | 840.00 |
| plastic, molded to patient model, reciprocating hip | ||
| joint and cables | ||
| L2628 | Addition to lower extremity, pelvic control, metal | 840.00 |
| frame, reciprocating hip joint and cables | ||
| L2630 | Addition to lower extremity, pelvic control, band | 166.88 |
| and belt, unilateral | ||
| L2640 | Addition to lower extremity, pelvic control, band | 201.60 |
| and belt, bilateral | ||
| L2650 | Addition to lower extremity, pelvic and thoracic | 86.80 |
| control, gluteal pad, each | ||
| L2660 | Addition to lower extremity, thoracic control, | 18.00 |
| thoracic band | ||
| L2670 | Addition to lower extremity, thoracic control, | 32.00 |
| paraspinal uprights | ||
| L2680 | Addition to lower extremity, thoracic control, | 32.00 |
| lateral support uprights | ||
| (d) ADDITIONS--GENERAL (L2750-L2999) | ||
| L2750 | Addition to lower extremity orthosis, plating | 52.00 |
| chrome or nickel, per bar | ||
| L2755 | High strength, lightweight material, all hybrid | 82.12 |
| lamination/prepeg composite, per segment, for custom | ||
| fabricated orthosis only | ||
| L2760 | Addition to lower extremity orthosis, extension, | 32.00 |
| per extension, per bar (for lineal adjustment for | ||
| growth) | ||
| L2768 | Orthotic side bar disconnect device, per bar | 81.01 |
| L2795 | Addition to lower extremity orthosis, knee control, | 62.21 |
| full kneecap | ||
| L2800 | Addition to lower extremity orthosis, knee control, | 64.80 |
| kneecap, medical or lateral pull | ||
| L2810 | Addition to lower extremity orthosis, knee control, | 54.57 |
| condylar pad | ||
| L2820 | Addition to lower extremity orthosis, soft | 40.68 |
| interface for molded plastic, below knee section | ||
| L2830 | Addition to lower extremity orthosis, soft | 40.68 |
| interface for molded plastic, above knee section | ||
| L2840 | Addition to lower extremity orthosis, tibial length | 28.00 |
| sock, fracture or equal, each | ||
| L2850 | Addition to lower extremity orthosis, femoral | 33.60 |
| length sock, fracture or equal, each | ||
| L2861 | Addition to lower extremity joint, knee or ankle, | B.R. |
| concentric adjustable torsion style mechanism for | ||
| custom fabricated orthotics only, each | ||
| L2999 | Unlisted procedures for lower extremity orthoses | B.R. |
| (e) FOOT, ORTHOPEDIC SHOES MODIFICATIONS, TRANSFERS | ||
| 1. FOOT, INSERTS, REMOVABLE, MOLDED TO PATIENT MODEL | ||
| L3000 | Foot insert, removable, molded to patient model, | 140.00 |
| "UCB" type, Berkeley shell, each | ||
| L3001 | Foot insert, removable, molded to patient model; | 76.00 |
| Spenco, each Qualifier: Custom Spenco device | ||
| L3002 | Foot insert, removable, molded to patient model, | 76.00 |
| Plastazote or equal, each | ||
| L3003 | Foot insert, removable, molded to patient model, | 76.00 |
| silicone gel, each | ||
| L3010 | Foot insert, removable, molded to patient model; | 76.00 |
| longitudinal arch support, each Qualifier: Any custom | ||
| leather/metal device (Example: Schaeffer, Whitman) | ||
| L3020 | Foot insert, removable, molded to patient model; | 88.00 |
| longitudinal/metatarsal support, each Qualifier: Any | ||
| custom leather/plastic device, full foot only | ||
| L3030 | Foot insert, removable, formed to patient foot, | 48.00 |
| each Qualifier: Only off-the-shelf Spenco | ||
| L3031 | Foot, insert/plate, removable, addition to lower | B.R. |
| extremity orthosis, high strength, lightweight | ||
| material, all hybrid lamination/prepreg composite, | ||
| each | ||
| 2. ARCH SUPPORTS, REMOVABLE, PREMOLDED | ||
| L3040 | Foot, arch support, removable, premolded; | 29.60 |
| longitudinal, each Qualifier: Only off-the-shelf | ||
| plastazote | ||
| L3050 | Foot, arch support, removable, premolded | 32.00 |
| metatarsal, each Qualifier: Only off-the-shelf with | ||
| metatarsal or heel pad with no longitudinal control | ||
| L3060 | Foot, arch support, removable, premolded, | 48.00 |
| longitudinal/metatarsal, each Qualifier: Only | ||
| off-the-shelf with longitudinal control | ||
| 3. ARCH SUPPORT, NON-REMOVABLE, ATTACHED TO SHOE | ||
| L3070 | Foot, arch support, nonremovable, attached to shoe, | 16.00 |
| longitudinal, each | ||
| L3080 | Foot, arch support, nonremovable, attached to shoe, | 20.00 |
| metatarsal, each | ||
| L3090 | Foot, arch support, nonremovable, attached to shoe | 24.00 |
| longitudinal/metatarsal, each | ||
| L3100 | Hallus-Valgus night dynamic splint | 20.00 |
| 4. ABDUCTION AND ROTATION BARS | ||
| L3140 | Foot, rotation positioning device, including | 56.00 |
| shoe(s) | ||
| L3150 | Foot, rotation positioning device, without shoe(s) | 60.00 |
| L3160 | Foot, adjustable shoe-style positioning device | B.R. |
| L3170 | Foot, plastic heel stabilizer | 112.00 |
| 5. ORTHOPEDIC FOOTWEAR | ||
| L3201 | Orthopedic shoe, oxford with supinator or pronator, | 48.00 |
| infant | ||
| L3202 | Orthopedic shoe, oxford with supinator or pronator, | 48.00 |
| child | ||
| L3203 | Orthopedic shoe, oxford with supinator or pronator, | 48.00 |
| junior | ||
| L3204 | Orthopedic shoe, hightop with supinator or | 48.00 |
| pronator, infant | ||
| L3206 | Orthopedic shoe, hightop with supinator or | 48.00 |
| pronator, child | ||
| L3207 | Orthopedic shoe, hightop with supinator or | 48.00 |
| pronator, junior | ||
| L3208 | Surgical boot, each infant | 24.00 |
| L3209 | Surgical boot, each child | 24.00 |
| L3211 | Surgical boot, each junior | 24.00 |
| L3212 | Benesch boot, pair, infant | 48.00 |
| L3213 | Benesch boot, pair, child | 48.00 |
| L3214 | Benesch boot, pair, junior | 48.00 |
| L3215 | Orthopedic footwear, ladies shoes, oxford | 76.00 |
| L3216 | Orthopedic footwear, ladies shoes, depth inlay | 100.00 |
| L3217 | Orthopedic footwear, ladies shoes, hightop, depth | 116.00 |
| inlay | ||
| L3219 | Orthopedic footwear, men's shoes, oxford | 76.00 |
| L3221 | Orthopedic footwear, men's shoes, depth inlay | 100.00 |
| L3222 | Orthopedic footwear, men's shoes, hightop, depth | 116.00 |
| inlay | ||
| L3224 | Orthopedic footwear, woman's shoe, oxford, used as | B.R. |
| an integral part of a brace (orthosis) | ||
| L3225 | Orthopedic footwear, man's shoe, oxford, used as an | B.R. |
| integral part of a brace (orthosis) | ||
| L3230 | Orthopedic footwear, custom shoes, depth inlay | 380.00 |
| L3250 | Orthopedic footwear, custom molded shoe, removable | 250.00 |
| inner mold, prosthetic shoe, each | ||
| L3251 | Foot, shoe molded to patient model, silicone shoe, | 280.00 |
| each | ||
| L3252 | Foot, shoe molded to patient model, Plastazote (or | 256.00 |
| similar), custom fabricated, each | ||
| L3253 | Foot, molded shoe Plastazote (or similar), custom | 112.00 |
| fitted, each | ||
| L3254 | Nonstandard size or width | 20.00 |
| L3255 | Nonstandard size or length | 20.00 |
| L3257 | Orthopedic footwear, additional charge for split | 50.00 |
| size | ||
| L3260 | Ambulatory surgical boot, each | 88.00 |
| L3265 | Plastazote sandal, each | 56.00 |
| 6. SHOE MODIFICATION--LIFTS | ||
| L3300 | Lift, elevation, heel, tapered to metatarsals, per | 64.00 |
| inch | ||
| L3310 | Lift, elevation, heel and sole, neoprene, per inch | 64.00 |
| L3320 | Lift, elevation, heel and sole, cork, per inch | 100.00 |
| L3330 | Lift, elevation, metal extension (skate) | 316.00 |
| L3332 | Lift, elevation, inside shoe, tapered, up to | 44.00 |
| one-half inch | ||
| L3334 | Lift, elevation, heel, per inch | 36.00 |
| 7. WEDGES | ||
| L3340 | Heel wedge, Sach | 10.40 |
| L3350 | Heel wedge | 12.00 |
| L3360 | Sole wedge, outside sole | 12.00 |
| L3370 | Sole wedge, between sole | 14.40 |
| L3380 | Clubfoot wedge | 12.00 |
| L3390 | Outflare wedge | 16.00 |
| L3400 | Metatarsal bar wedge, rocker | 16.00 |
| L3410 | Metatarsal bar wedge, between sole | 16.00 |
| L3420 | Full sole and heel wedge, between sole | 24.00 |
| L3430 | Heel, counter, plastic reinforced | 24.00 |
| L3440 | Heel, counter, leather reinforced | 24.00 |
| L3450 | Heel, Sach cushion type | 64.00 |
| L3455 | Heel, new leather, standard | 8.00 |
| L3460 | Heel, new rubber, standard | 8.00 |
| L3465 | Heel, Thomas with wedge | 20.00 |
| L3470 | Heel, Thomas extended to ball | 24.00 |
| L3480 | Heel, pad and depression for spur | 16.00 |
| L3485 | Heel, pad, removable for spur | 32.00 |
| 8. MISCELLANEOUS SHOE ADDITIONS | ||
| L3500 | Miscellaneous shoe addition, insole, leather | 4.00 |
| L3510 | Miscellaneous shoe addition, insole, rubber | 8.00 |
| L3520 | Miscellaneous shoe additions, insole, felt covered | 8.00 |
| with leather | ||
| L3530 | Miscellaneous shoe addition, sole, half | 12.00 |
| L3540 | Miscellaneous shoe addition, sole, full | 36.00 |
| L3550 | Miscellaneous shoe addition, toe tap, standard | 4.00 |
| L3560 | Miscellaneous shoe addition, toe tap, horseshoe | 6.40 |
| L3570 | Miscellaneous shoe addition, special extension to | 152.00 |
| instep (leather with eyelets) | ||
| L3580 | Miscellaneous shoe addition, convert instep to | 13.60 |
| Velcro closure | ||
| L3590 | Miscellaneous shoe addition, convert firm shoe | 28.00 |
| counter to soft counter | ||
| L3595 | Miscellaneous shoe addition, March bar | 12.00 |
| 9. TRANSFER OR REPLACEMENT | ||
| L3600 | Transfer of an orthosis from one shoe to another, | 48.00 |
| caliper plate, existing | ||
| L3610 | Transfer of an orthosis from one shoe to another, | 76.00 |
| caliper plate, new | ||
| L3620 | Transfer of an orthosis from one shoe to another, | 39.04 |
| solid stirrup, existing | ||
| L3630 | Transfer of an orthosis from one shoe to another, | 76.00 |
| solid stirrup, new | ||
| L3640 | Transfer of an orthosis from one shoe to another, | 28.00 |
| Dennis Browne splint (Riveton), both shoes | ||
| L3649 | Unlisted procedures for foot orthopedic shoes, shoe | B.R. |
| modifications and transfers | ||
| (f) ORTHOTIC DEVICES--UPPER LIMB (L3650-L3999) | ||
| Note: The procedures in this section are considered as "base" or "basic | ||
| procedures" and may be modified by listing procedures from the "additions" | ||
| sections and adding them to the base procedure. | ||
| 1. UPPER LIMB: SHOULDER | ||
| L3650 | Shoulder orthosis, (SO), figure of "8" design | 32.00 |
| abduction restrainer | ||
| L3660 | SO, figure of "8" design abduction restrainer, | 60.00 |
| canvas and webbing | ||
| L3670 | SO, acromion/clavicular (canvas and webbing type) | 88.62 |
| L3671 | Shoulder orthosis, shoulder cap design, without | 507.32 |
| joints, may include soft interface, straps, custom | ||
| fabricated, includes fitting and adjustment | ||
| L3672 | Shoulder orthosis, abduction positioning (airplane | 630.88 |
| design), thoracic component and support bar, without | ||
| joints, may include soft interface, straps, custom | ||
| fabricated, includes fitting and adjustment | ||
| L3673 | Shoulder orthosis, abduction positioning (airplane | 687.58 |
| design), thoracic component and support bar, includes | ||
| non torsion joint/turnbuckle, may include soft | ||
| interface, straps, custom fabricated, includes fitting | ||
| and adjustment | ||
| L3675 | Shoulder orthosis, (SO); vest type abduction | 85.92 |
| restrainer, canvas webbing type, or equal | ||
| L3677 | Hard plastic, shoulder stabilizer, prefabricated, | B.R. |
| includes fitting and adjustment | ||
| 2. UPPER LIMB: ELBOW | ||
| L3702 | Elbow orthosis (EO), without joints, may include | 162.57 |
| soft interface, straps, custom fabricated, includes | ||
| fitting and adjustment | ||
| L3710 | EO, elastic with metal joints | 60.00 |
| L3720 | EO, double upright with forearm/arm cuffs, free | 520.00 |
| motion | ||
| L3730 | EO, double upright with forearm/arm cuffs, | 617.71 |
| extension/flexion assist | ||
| L3740 | EO, double upright with forearm/arm cuffs, | 692.08 |
| adjustable position with lock with active control | ||
| L3760 | Elbow orthosis (EO), with adjustable position | 272.89 |
| locking joint(s), prefabricated, includes fitting and | ||
| adjustment | ||
| L3762 | Elbow orthosis, rigid, without joints, includes | 61.51 |
| soft interface material prefabricated, includes | ||
| fitting and adjustment | ||
| 3. UPPER LIMB: WRIST-HAND-FINGER | ||
| L3763 | Elbow wrist hand orthosis; rigid, without joints, | 433.83 |
| may include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3764 | Elbow wrist hand orthosis; includes one or more | 545.99 |
| nontorsion joints, elastic bands, turnbuckles, may | ||
| include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3765 | Elbow wrist hand finger orthosis, rigid without | 721.91 |
| joints, may include soft interface, straps, custom | ||
| fabricated, includes fitting and adjustment | ||
| L3766 | Elbow wrist hand finger orthosis, includes one or | 764.45 |
| more nontorsion joints, elastic bands, turnbuckles, | ||
| may include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3806 | Wrist-hand-finger-orthoses (WHFO); includes one or | 255.75 |
| more nontorsion joint(s), turnbuckles, elastic | ||
| bands/springs, may include soft interface material, | ||
| straps, custom fabricated, includes fitting and | ||
| adjustment | ||
| L3807 | WHFO, extension assist, with inflatable Palmer Air | 135.08 |
| support, with or without thumb extension | ||
| L3808 | Wrist-hand-finger-orthoses (WHFO); rigid without | 228.44 |
| joints, may include soft interface material; straps, | ||
| custom fabricated, includes fitting and adjustment | ||
| 4. ADDITIONS | ||
| L3891 | Addition to upper extremity joint, wrist or elbow, | B.R. |
| concentric adjustable torsion style mechanism for | ||
| custom fabricated orthotics only, each | ||
| 5. DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/FLEXION, | ||
| FINGER FLEXION/EXTENSION | ||
| L3900 | WHFO, dynamic flexor hinge; reciprocal wrist | 800.00 |
| extension/flexion, finger flexion/extension, wrist or | ||
| finger driven | ||
| L3901 | WHFO, dynamic flexor hinge; reciprocal wrist | 884.00 |
| extension/flexion, finger flexion/extension, cable | ||
| driven | ||
| 6. EXTERNAL POWER | ||
| L3904 | WHFO, external powered, electric | 369.00 |
| L3905 | Wrist hand orthosis, includes one or more | 558.35 |
| nontorsion joints, elastic bands, turnbuckles, may | ||
| include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| 7. OTHER WRIST-HAND-FINGER ORTHOSES--CUSTOM FITTED | ||
| L3906 | WHFO, wrist gauntlet, molded to patient model | 267.41 |
| L3908 | WHFO, wrist extension control cock-up, non-molded | 50.13 |
| L3911 | Wrist hand finger orthosis, elastic, prefabricated, | B.R. |
| includes fitting and adjustment (for example, | ||
| neoprene, lycra) | ||
| L3912 | WHFO, flexion glove with elastic finger control | 67.25 |
| L3913 | Hand finger orthosis, without joints, may include | 152.49 |
| soft interface, straps, custom fabricated, includes | ||
| fitting and adjustment | ||
| L3915 | Wrist-hand orthosis, includes one or more | 299.27 |
| nontorsion joint(s), elastic bands, turnbuckles, may | ||
| include soft interface straps, prefabricated, includes | ||
| fitting and adjustment | ||
| L3917 | Hand orthosis, metacarpal fracture orthosis, | 22.26 |
| prefabricated, includes fitting and adjustment | ||
| 8. UPPER LIMB: SHOULDER-ELBOW-WRIST-HAND ABDUCTION | ||
| POSITIONING--CUSTOM FITTED | ||
| L3960 | Shoulder-elbow-wrist-hand orthosis (SEWHO), | 460.00 |
| abduction positioning, airplane design | ||
| L3961 | SEWHO, shoulder cap design, without joints, may | 945.92 |
| include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3962 | SEWHO, abduction positioning, Erbs Palsey design | 420.00 |
| L3963 | SEWHO, molded shoulder, arm, forearm, and wrist, | 847.70 |
| with articulating elbow joint | ||
| L3964 | SEWHO, mobile arm support attached to wheelchair, | 520.00 |
| balanced and fitted to patient, adjustable | ||
| L3965 | SEWHO, radial arm support attached to wheelchair, | 759.66 |
| balanced and fitted to patient, adjustable rancho type | ||
| L3966 | SEWHO, mobile arm support attached to wheelchair, | 488.00 |
| balanced and fitted to patient, reclining | ||
| L3967 | SEWHO, abduction positioning (airplane design), | 1,116.82 |
| thoracic component and support bar, without joints, | ||
| may include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3968 | SEWHO, mobile arm support attached to wheelchair, | 680.00 |
| balanced and fitted to patient, friction arm support | ||
| (friction dampening to proximal and distal joints) | ||
| L3969 | SEWHO, mobile arm support, monosuspension arm and | 417.06 |
| hand support, overhead elbow forearm hand sling | ||
| support, yoke type arm suspension support | ||
| 9. ADDITIONS TO MOBILE ARM SUPPORTS | ||
| L3970 | SEWHO, addition to mobile arm support, elevating | 200.00 |
| proximal arm | ||
| L3971 | SEWHO, shoulder cap design, includes one or more | 1,060.12 |
| nontorsion joints, elastic bands, turnbuckles, may | ||
| include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3972 | SEWHO, addition to mobile arm support, offset or | 112.00 |
| lateral rocker arm with elastic balance control | ||
| L3973 | SEWHO, abduction positioning (airplane design), | 1,116.82 |
| thoracic component and support bar, includes one or | ||
| more nontorsion joints, elastic bands, turnbuckles, | ||
| may include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3974 | SEWHO, addition to mobile arm support, supinator | 112.00 |
| L3975 | SEWHO, without joints, may include soft interface, | 945.92 |
| straps, custom fabricated, includes fitting and | ||
| adjustment | ||
| L3976 | SEWHO, abduction positioning (airplane design), | 945.92 |
| thoracic component and support bar, without joints, | ||
| may include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3977 | SEWHO, shoulder cap design, includes one or more | 1,060.12 |
| nontorsion joints, elastic bands, turnbuckles, may | ||
| include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3978 | SEWHO, abduction positioning (airplane design), | 1,116.82 |
| thoracic component and support bar, includes one or | ||
| more nontorsion joints, elastic bands, turnbuckles, | ||
| may include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| 10. UPPER LIMB--FRACTURE ORTHOSIS | ||
| L3980 | Upper extremity fracture orthosis, humeral | 163.17 |
| L3982 | Upper extremity fracture orthosis, radius/ulnar | 172.00 |
| L3984 | Upper extremity fracture orthosis, wrist | 122.40 |
| L3995 | Addition to upper extremity orthosis, sock, | 14.80 |
| fracture or equal, each | ||
| L3999 | Unlisted procedures for upper limb orthosis | B.R. |
| (g) SPECIFIC REPAIR (L4000-L4199) | ||
| L4000 | Replace girdle for Milwaukee orthosis | 696.00 |
| L4002 | Replacement strap, any orthosis, includes all | 18.00 |
| components, any length, any type | ||
| L4010 | Replace trilateral socket brim | 444.59 |
| L4020 | Replace quadrilateral socket brim, molded to | 532.00 |
| patient model | ||
| L4030 | Replace quadrilateral socket brim, custom fitted | 373.06 |
| L4040 | Replace molded thigh lacer | 272.53 |
| L4045 | Replace nonmolded thigh lacer | 140.00 |
| L4050 | Replace molded calf lacer | 331.80 |
| L4055 | Replace nonmolded calf lacer | 61.02 |
| L4060 | Replace high roll cuff | 136.00 |
| L4070 | Replace proximal and distal upright for KAFO | 168.00 |
| L4080 | Replace metal bands KAFO, proximal thigh | 72.00 |
| L4090 | Replace metal bands KAFO-AFO, calf or distal thigh | 60.00 |
| L4100 | Replace leather cuff KAFO, proximal thigh | 80.00 |
| L4110 | Replace leather cuff KAFO-AFO, calf or distal thigh | 52.00 |
| L4130 | Replace pretibial shell | 331.45 |
| (h) REPAIRS (L4200-L4299) | ||
| L4205 | Repair of orthotic device, quarter-hour rate | 10.60 |
| L4210 | Repair of orthotic device, repair or replace minor | 69.00 |
| parts | ||
| (i) ANCILLARY ORTHOTIC SERVICES (L4300-L4399 AND X3680) | ||
| L4350 | Pneumatic ankle control splint (for example, | 52.00 |
| aircast) | ||
| L4360 | Pneumatic walking splint (for example, aircast) | 160.00 |
| L4370 | Pneumatic full leg splint (for example, aircast) | 88.00 |
| L4380 | Pneumatic knee splint (for example, aircast) | 56.00 |
| L4386 | Non-pneumatic walking splint, with or without | 99.66 |
| joints, prefabricated, includes fitting and adjustment | ||
| L4392 | Replace soft interface material, ankle contracture | 13.56 |
| splint | ||
| L4394 | Replace soft interface material, foot drop splint | 9.90 |
| L4396 | Ankle contracture splint | 96.67 |
| L4398 | Foot drop splint, recumbent positioning device | 44.52 |
| X3680 | Travel time per round trip, per day | 40.72 |
N.J. Admin. Code § 10:55-2.3
See: 30 N.J.R. 512(a), 30 N.J.R. 2919(a).
In (c) and (i), inserted new Codes.
Amended by R.1999 d.40, effective 2/1/1999.
See: 30 N.J.R. 3897(a), 31 N.J.R. 439(a).
In (a), added L0999; in (c), inserted L1843 and L2035; and in (e), added Qualifiers in L3001, L3010, L3020, L3030, L3040, L3050 and L3060, and deleted X4800, X4801, X4802, X4803, X4804 and X4805.
Amended by R.1999 d.391, effective 11/15/1999.
See: 31 N.J.R. 2291(b), 31 N.J.R. 3635(a).
In (c), inserted L1690 and L1847; in (f), inserted L3675; and in (i), deleted L4310 and L4320.
Amended by R.2000 d.134, effective 4/3/2000.
See: 31 N.J.R. 3964(a), 32 N.J.R. 1206(a).
In (d), inserted a reference to L2860; in (e), inserted references to L3160, L3224 and L3225; and in (f), inserted a reference to L3890.
Amended by R.2000 d.463, effective 11/20/2000.
See: 32 N.J.R. 2974(a), 32 N.J.R. 4108(a).
In (f), inserted a reference to L3807.
Amended by R.2004 d.406, effective 11/1/2004.
See: 35 N.J.R. 4417(a), 36 N.J.R. 4963(a).
Rewrote the section.
Amended by R.2005 d.312, effective 9/19/2005.
See: 37 N.J.R. 933(a), 37 N.J.R. 3697(a).
Rewrote (a)-(c), (e), (f), and (h).
Amended by R.2009 d.93, effective 3/16/2009.
See: 40 N.J.R. 3912(a), 41 N.J.R. 1245(a).
In the introductory language of (i), inserted "AND X3680"; and in the "Description" column of entry "X3680" in the table in (i), substituted "round trip, per day" for "hour (specify time involved)".
Amended by R.2011 d.080, effective 3/7/2011.
See: 42 N.J.R. 2179(a), 43 N.J.R. 622(a).
Rewrote (a) through (g).